Microsoft word - manual therapy magical trick or science.doc

Introduction to a series of articles.

First let me introduce myself. My name is Ger Plaatsman. For the last 30 years I have been
practising, studying and teaching manual therapy. In 1994 I started the Plaatsman Concept of
Evidence based manual therapy in Poland. At first only in corporation with the Katowice
branch of PTF and AWF Katowice and later also in city’s like Warsaw and Wroclaw. During
my courses here in Poland I am being translated by professor Edward Saulicz from AWF
Katowice. Together we have managed to train already more than 1.500 Polish
physiotherapists in the basic skills of manual therapy. The courses of the Plaatsman concept
are three parts of 7 days. In those three parts the student will learn how to examine and treat
people manual therapeutic.
During my many years in Poland I came in contact with mr. Piotr Dudar from Sumer
company. He started to lend me his treatment tables during my courses with great satisfaction.
And I have to say I am very critical about my working conditions and therefor a good table
means everything to me. One of the nice things about the co-orporation with Sumer was that I
was allowed to construct a table especially for manual therapy.
So of course when mr. Dudar of Sumer company asked me if I would like to write little
articles and case reports on his website I said yes. The meaning of these editorials is to give
the reader an impression of what manual therapy is.
The first article is ment to show that manual therapy is more science than magic.

Manual therapy, magical trick or science.
When I first started teaching manual therapy in Poland, in 1994, it was an unknown type of
therapy. Many therapists thought that you could heal every patient with a few simple
manipulations. I do agree that it sometimes looks like that but the truth is different.
There are different ways to look at the pathology of a patient. There are also different
methods in manual therapy. Although so called bone setting (repositioning of two bones that
are out of order) is of all times, modern manual therapy goes back to America in the second
half of the 19th century. In 1874 A.T. Still proposed an alternative medical practice, which he
called Osteopathy. His idea was that there is a clear interrelationship between structure and
function of the body. He recognized the body's ability to heal itself. One of his ways to help
the body help it self, was by manipulation and mobilization of the joints. Also in Europe
therapists and doctors started using manipulations and mobilizations in addition to massage
and exercises to heal mechanical problems of the human locomotive system.
Manipulations and mobilizations to help the body heal itself. Yes it sounds very good, and it
is. But what technique on what part of the body to help healing what? That is a question
where we need science to answer it.
There is an example out of normal life I always use to explain this. Suppose that your car is
leaking oil and you bring it to the auto repair shop. Than when you pick up your, repaired,
car, you find out that the only thing the mechanic did was putting 2 litres of new oil in it. Of
course when your car is 12 years old and has 300.000 Km on it you will accept this solution.
But when the car is only 2 years old with a few thousand Km on it you will not accept this
and ask the mechanic where he learned his profession. You would expect that this mechanic
would look for the cause of the leaking oil. This always interests me. People do not accept a
treatment of the symptoms (leaking oil) with their car, but do accept an Aspirin, or massage,
for the symptom pain. Should we as therapists and doctors not become a better car repair
mechanic and start looking for the cause of, the patients, problem rather than solving it’s
symptoms? Yes but how?
One of the answers lies in the ability of clinical reasoning. Clinical reasoning refers to a
process in which the therapist, interacting with the patient, structures meaning, goals & health management strategies based on clinical data, client choices, professional judgment & knowledge (Higgs and Jones 2000). This may sound complicated but can be translated as “ on which information I decide to do what to this patient”. So it is actually a decision-making process. A second thing which the definition of Higgs and Jones talks about is clinical data, this means science. When we see a patient for the first time we already know many things of him and we can already put him in subgroups. Subgroups are the first step in making clinical decisions. Why? Simple, a man cannot become pregnant and a woman has no change to get prostate cancer. Age is the second information we can use. With the use of statistics we know that it is not common for young people to have artrosis deformans. So if a young person comes to you in the practice with symptoms of artrosis, you know that there must be a reason other than degeneration seen in older people. The science, or magical trick if you want, lies in the ability to find out why a patient presents himself with a condition you do not expect. As mentioned, placing the patient in a subgroup is the first step. Man or woman, old or young, skinny or fat, tall or small, active life or sitting all day and many more. A second step, and indeed a very important which is forgotten too many times, is if the patient has or had any other problems of the locomotive system which we can connect to the present complaint. A very good way to not forget any of these is a bodychart. The bodychart is a drawing of the human body in the anatomical position seen from the front and the back. This drawing was first used by Maitland. You ask the patient to describe his pain or problem and then draw it into the bodychart. In order to not forget anything you ask, systematically from head to toes, if the patient has, or had, problems in the different areas of the body. If so you also draw it in to the body chart. Doing so you can even put the person in a new subgroup. The third step is the anamneses. You will ask specific questions like: please describe what the pain feels like and how much is this pain on a scale of 1 to 10. One of the most important questions is “ which movement, activity or posture starts your pain. After this you will have to ask about the relation between the present pain and the other areas of pain. This because it is very well possible that back pain is the result of an ankle problem that has not healed completely and the body decides to walk different to take the weight of this foot, resulting in overload on another part of the body. After getting all this information we can set up different hypotheses of what the cause of the problem can be. The fourth step will be to prove these hypotheses during physical examination. Once we proved our hypotheses about the cause of the patient’s problem we can start thinking about the proper solution. One of the first questions to be answered is; can we use quick techniques, manipulation, or should we mobilize. This question, again, can be answered with the help of scientific research. Evidence shows that manipulations help the most in acute situations and have a quick result. For instance when a patient with low back pain presents himself within 16 days with pain not radiating below the knee and a difference in external rotation of one hip (prediction rules by Childs 2004) then he has a 82% chance that his condition will be healed by a single manipulation of the lumbosacral junction. On the other hand when a condition is present for longer than 12 weeks it is proven that manipulations have less result than a combination of exercises and mobilizations (European guidelines for the management of chronic non-specific low back pain). During my courses I explain that a weak, or shortened, muscle cannot always be treated by strengthening or stretching. This because the reason that this muscle is weak or shortened can be that his function will irritate or protect the lesion of the patient. (This phenomenon, called NSB according to Brügger can also be used for diagnostics). Before and after each technique, used during treatment, the manual therapist has to do an objective reproducible test. The difference between the two tests will be the result of your technique used. Different outcomes can be interpreted and used to choose the next step in the treatment. Yes if you are able to find the right treatment technique for your patient, with the help of science and clinical reasoning, it sometimes looks like magic for the patient. Of course it is not possible to explain the whole system of manual therapy in a little article. But over the next time I will write more of these editorials to give the reader an idea what else we can do with a patient besides massage and in the fittnessstudio.


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